Healthcare Provider Details

I. General information

NPI: 1407129786
Provider Name (Legal Business Name): BRAD RYAN NEDEROSTEK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S 2ND ST SUITE 180
MINNEAPOLIS MN
55454-1075
US

IV. Provider business mailing address

4301 PARK GLEN RD APARTMENT 132
SAINT LOUIS PARK MN
55416-4783
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-1500
  • Fax:
Mailing address:
  • Phone: 610-533-1911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: